Spoonerisms or malapropisms, commonly referred to as slips of the tongue, are a perfectly natural aspect of communication. They’re also the source of much amusement. Who doesn’t enjoy hearing lexically confused celebrities – Justin Bieber once claimed he was ‘detrimental to his own career’ – though I reserve most of my delight for the communicative cockups of politicians. Trump and Bush Jnr are well known for their weird wordery, but here’s a goody from Tony Abbott, former PM of Australia: ‘No one, however smart, however well-educated, however experienced … is the suppository of all wisdom.’ I feel a joke forming – no. Can’t. Too rude.
Remember former US Vice-President Dan Quale? He famously came out with ’I stand by all the misstatements that I’ve made’ while Richard J Daley, former mayor of Chicago, uttered some gems during his term in office, once calling a tandem bicycle a ‘tantrum bicycle’ and referring to Alcoholics Anonymous as ‘Alcoholics Unanimous’.
These days, we’re certainly more aware of slip-ups, errors and abuses because so much is being written, not only in emails but on social media, in forums, blogs and newspaper comments sections. We also seem far more tolerant of spelling mistakes and grammar oddities (assuming we’ve spotted them in the first place). If you doubt this, correct someone in the Comments section of a newspaper and see what happens. The so-called grammar police – who really seem more concerned with punctuation and spelling than structure and form – get short shrift when they pop up to correct a misplaced apostrophe.
Meaning is an altogether more slippery beast
But meaning is an altogether more slippery beast. When communication takes place, and language competency is not called into question – that is to say, both participants are judged to be proficient in whatever language they’re using – each participant assumes that lexical choices are deliberate and appropriate. You rarely see vocabulary being corrected. If you tell me you’ve eaten four doughnuts, I’m not going to be too impressed, but I’ll believe you. I may well seek confirmation – four? FOUR? – but I won’t wonder if you really meant one or that you intended to say sandwich. If you tell me you’re a plumber, I won’t wonder if you meant fitness instructor. It gets trickier, though, when faced with less concrete, stodgy facts. ‘How are you feeling today’ or ‘Does this make me look fat?’ doesn’t always lead to an unequivocal response. I’m likely still confident that you’ve chosen the word you wanted, but I may not always be sure of the accuracy of the message or its veracity. Aside from bare faced lies, there are white lies, half-truths, evasive responses and vaguery. You could write a book on these aspects of communication – plenty of people have. I’ll talk a bit about it in my next blog post.
But what happens when a mother tongue is not shared, or language competency is not evenly matched? With their multicultural populations, this is a typical scenario in many urban medical encounters in countries like the UK, the US Canada and Australia. Even without the challenges of accent and pronunciation, grammar issues and health literacy issues, miscommunication because of vocabulary is a common source of frustration, confusion and, sometimes, medical error. Unlike the rarefied atmosphere of the classroom, where students are safe to make mistakes, and where there’s time to investigate the collocations, connotation, range of meaning, register and appropriacy of a single word, a real-time medical interaction permits no such analysis.
Meaning in medical encounters
When we speak about communication issues in medical encounters, we’re often referring to those interactions where the patient doesn’t understand or fully understand what their doctor is saying. Over the last decade or so, many papers have investigated just how little medical terminology patients understand, and the impact of not understanding on the patient’s health and well-being. (See for example Chapman, K., Abraham, C., Jenkins, V., & Fallowfield, L. (2003)). Studies like these continue to appear in disciplines other than applied linguistics and for a variety of languages and areas of medicine.
Some linguists and healthcare communication researchers have shifted their focus away from what patients don’t understand and on to what they do understand and how they use the medical terms that they know. (Fage-Butler & Jensen (2016) and Koch-Weser, de Jong & Rudd, (2009; 2010) are well worth reading.) These studies reveal a considerably more complex picture than the standard understand/do not understand dichotomy. The so-called ‘expert patient’ – often a patient living with a chronic condition – has been described as having a kind of ‘vertical knowledge’ which suggests that they can use ( a lot of complex) medical terminology relevant to their condition. In light of these findings, assessing what the patient understands or doesn’t understand should be an essential part of the consultation. As Fage Butler and Jensen (ibid) write:
Appropriate pitching of terms can avoid the potentially damaging eﬀects of poor communication brought about by inappropriate (too complex or too simple) use of terms. This is not an easy task. It takes time for a health-care professional to establish what terminological level is appropriate, which can be problematic in an already time-pressed consultation.
The authors also make clear that we need to be cautious in assuming that patients and medical professionals are using medical terminology in the same way. This is a hugely important point. Meaning divergence, as this is called, can often pass unnoticed with both participants assuming a common, shared meaning where in fact none exists. For example, in oncology, talk of disease progression may pass without comment, but the patient may not have understood that this is not something to be pleased about. Another example of this – and it’s one I like to trot out because it a great example – is the term ‘chronic’. How many international health professionals know that it can be used in certain varieties of English to mean ‘bad’? If I tell my doctor my pain is chronic because it’s intense, the doctor is likely to understand that I’ve had it for some time and the remark may pass without comment. Dahm (2012) found that people (and that includes medical professionals) are more aware of meaning divergence when they’ve had personal experience of it. She also found that the very concept of meaning divergence can be difficult to grasp for some people. For some, it can mean that the severity of my condition, the intensity of my pain or the impact on my life is not being fully understood or appreciated by you.
The role of experience in how we understand words
Experience also plays a role in how we all use and understand words. Patients may use terms differently to medical professionals because as patients we emphasise the experience of the condition or symptom, and, just as personal experience of a condition varies from one person to another, so do the meanings attached to the words we use. In the same way, medical professionals will understand different aspects of the same word depending on their experience and area of expertise. A psychiatrist will have quite a different understanding of the term ‘schizophrenia’ than a GP. The patient with schizophrenia, in turn, possesses a different understanding to both psychiatrist and GP. This is a fascinating area. (Professor John Skelton, EALTHY President, alerted me to this a few years ago, though he expressed it far more elegantly than I have just done.)
So, as teachers of medical English what can we take from this? Well, the obvious thing is that Meaning is a Minefield (there’s a good summary of just how complex it is to talk about meaning here: https://plato.stanford.edu/entries/word-meaning/ ) and our students should be made aware that simple translations won’t necessarily cut it. Words have very intricate relationships with other words and with the context in which they’re used. Developing our students’ awareness of this seems crucial. And as human beings, our relationships with each other and how we communicate are equally as intricate. We teachers can never hope to give our healthcare students all the knowledge they need to be competent communicators when they leave our classrooms, but we can help them acquire the skills they need to become effective communicators. These skills will develop as their professional skills and experience grow. Medical professionals using English in the workplace, more than anything else in my view, need the linguistic means to negotiate meaning with their patients and their colleagues, and to negotiate meaning with skill, with sensitivity and with the awareness that each and every interaction is unique.
I’ll leave you with a few medical malaprops that had me in stitches. Literally. Not. (😉 )
- She had postmortem (postpartum) depression
- Heart populations and high pretension (palpitations and hypertension)
- A case of headlights (head lice)
- Sick as hell anemia (sickle cell anemia)
- The blood vessels were ecstatic (ectatic)
- The patient was treated for Paris Fevers (paresthesias)
- It was a non-respectable (unresectable) tumor
- Nerve testing was done using a pink prick (pinprick) test
- I had smiling mighty Jesus (spinal meningitis)